Provider Demographics
NPI:1700862042
Name:MONROE, NICOLE YVONNE (OD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:YVONNE
Last Name:MONROE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:YVONNE
Other - Last Name:STEINER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6947 CRUMPLER BLVD SUITE 100
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1922
Mailing Address - Country:US
Mailing Address - Phone:662-893-3300
Mailing Address - Fax:662-893-3301
Practice Address - Street 1:6947 CRUMPLER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1922
Practice Address - Country:US
Practice Address - Phone:662-893-3300
Practice Address - Fax:662-893-3301
Is Sole Proprietor?:No
Enumeration Date:2005-12-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS647152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00802007Medicaid
TN2001OtherSTATE LICENSE
MM1188817OtherDEA
MM1188817OtherDEA
TN2001OtherSTATE LICENSE